Source of income for all adults on file (Social Assistance, Disability Student Loans, Pay Stubs, etc.)

I.D. for all adults (persons over 18 years). This can be in the form of a Driver's Licence, Care Card, Student ID, B.C. I.D. or social insurance number.

I.D. for all minors (persons under 18 years). This can be in the form of a BC Care Card or Birth Certificate.

How to Register

You may register by attending the food bank on Thursdays between the hours of 1:00 and 2:30. You may print off the application form and bring it with you or you may complete our online application form. REMEMBER TO BRING SUPPORTING DOCUMENTATION AS NOTED ABOVE.

Applicant Information

Name *

Name

First Name

Last Name

Date *

Date

MM

DD

YYYY

Address *

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Phone

(###)

###

####

Email Address *

Driver's Licence # *

Secondary ID *

Family Information

Family Information

Household Members *

Include name, date of birth, age, bc health care number and relationship to applicant

Family Composition *

Single Person

Couple

Single Parent Family

Two Parent Family

Multigenerational Family

Grandparents

Housing Type

Type of Housing *

Landlord Information

Monthly Income

Total monthly HOUSEHOLD income

Employment Income

$

Name and Phone Number of Employer

Employment Insurance (EI)

$

Disability

$

Child Tax Credit

$

GST Credit

$

Pension Income

$

Social AssistanceStudent

$

Student Financing

$

Other Income

$

TOTAL MONTHLY INCOME *

$

Monthly Expenses

Total Household Expenses

Rent/Mortgage

$

Heating Fuel (oil/natural gas)

$

Electric

$

Water/Sewer

$

Phone

$

Cable

$

Transportation

$

Insurance

$

Daycare

$

Other

$

TOTAL MONTHLY EXPENSES *

$

RECIPIENT UNDERSTANDING AND DECLARATION OF INFORMATION

Declaration *

I understand that I am assigned a hamper day and I must arrive at least ½ hour prior to the scheduled food bank closure hours. Unexpected drop-in is not encouraged and may result in a request to return on your assigned day. Emergency situations are on a case-by-case basis and approved by the Food Bank coordinator prior to a change in an assigned day.
There is a zero tolerance for verbal and physical abuse. Observation of recent drug or alcohol usage will result in a request to leave the premises.
A FOOD HAMPER MAY CONTAIN:
A "best before" or "use by date" that has expired *canned food may be dented; discard after opening if contents spray out after opening (note: canned goods are good past their expiry date for up to 4 years). I AGREE to use ALL items as soon as possible and accept ANY risk associated as noted above however, if there is a concern, it is suggested you discard such items.
I DECLARE that the information given is truthful and that income information has not been withheld or misrepresented. Misrepresentation includes claiming single status rather than couple status, children and other adults residing in the residence that change the status to family. The hamper status determines the size of the hamper received. Misrepresentation of any information may result in being dismissed from using the Lake Country Food Bank.
*Should questions arise based on the information provided, a further request for documentation may be requested. The Lake Country Food Bank reserves the right to verify the information provided. The Lake Country Food Bank may contact other area Food Banks to ensure that there is no "double dipping". The exception to the rule is using the Salvation Army resources in Kelowna.

I agree to the Recipient Understanding and Declaration of information.

Thank you. Please attend our office with your supporting documentation and identification on Thursday between 1:00 and 2:30. If you require an emergency hamper, please contact us at 250-766-0125